Band 2, Heft 4

High energy deficits due to underfeeding are frequently observed during critical illness and are associated with significant morbidity and mortality. Adequate determination of energy requirements is imperative for optimizing nutrition. For this goal, indirect calorimetry is considered to be the gold standard but it is expensive, time-consuming, and not readily available in many hospitals. As an alternative, most ICU physicians use bedside formulas to predict calorie needs. Some equations are obtained during resting metabolism in healthy humans and “corrected” by adding stress or injury factors. Others are derived from regression analysis in patients whereby various static and dynamic variables are identified and eventually adjusted for type of patient and/or disease. Few studies have evaluated the accuracy of predictive equations in critically ill patients. The largest prospective study to date identified the Penn State equation, including a modified version for obesity, as being the most accurate. Whether the systematic use of (a) particular formula(s) for estimating calorie needs may influence morbidity or outcome in ICU patients remains to be determined.

Acute respiratory distress syndrome (ARDS) is a major cause of morbidity, death and cost in intensive care units. ARDS was first described in 1967, and the new definition was determined as the Berlin definition in 2011 in Berlin. ARDS is a syndrome of inflammation and increased permeability of the blood-gas barrier. Despite intensive research, treatments remain limited and supportive therapies represent the mainstay of the treatment of ARDS. This inability of therapeutic modalities largely depends on the complex pathogenesis of this syndrome with multiple overlapping signaling pathways activated depending on the type of lung injury. Today, this syndrome is still associated with a high morbidity and mortality. Animal models provide us a bridge between bench and bedside. Numerous different models have been developed in order to establish the properties of ARDS, but, to date, no single animal model that mimics all of the characteristics of ARDS in humans has been developed, and most of the existing animal models are relevant only for limited aspects of human ARDS. Furthermore, each animal model has unique features that affect responses to treatment. Therefore, when choosing an animal model of ARDS, to take into account the key feature of ARDS as a working hypothesis to be tested and then create the most appropriate model to exhibit those features is important. The goal of this review is to summarize the properties of the most commonly used experimental animal models of ARDS after mentioning briefly the causes and pathophysiology.

Acute respiratory distress syndrome is a common syndrome in clinical practice, particularly in the Intensive Care Unit (ICU), with a high morbidity and mortality rate. The prerequisite of its early treatment is early diagnosis. The early biomarkers hence have been gradually favored. While some new and original biomarkers continue to be the focus of research, some biomarkers such as C-reactive protein and procalcitonin have been widely used in clinical practice.

Objective: The aim of this study was to determine the significance of the ratio of diameter of left lobe of liver with serum albumin as a non-invasive predictor of esophageal varices. Materials and Methods: All consecutive patients with clinical cirrhosis were included in the study. The study was conducted in the Department of Gastroenterology and Hepatology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan. All patients underwent full history taking, clinical examination, relevant laboratory investigations and abdominal ultrasound evaluation. Measurement of the right liver lobe diameter (RLLD) and left liver lobe diameter (LLLD) was performed using ultrasound in the mid-clavicular line and central line, respectively. Esophago-gastroscopy was performed for the detection and grading of esophageal varices. Calculation of the RLLD and LLLD/serum albumin ratio was performed and analyzed for clinical significance. Results: One hundred and eleven subjects (80 males; 72%), with a mean age of 40.09 ± 13.6 years were studied. Esophageal varices were seen in 68 (61.3%) patients and Child-Pugh class A accounted for 41.4%, class B for 45.9% and class C for 12.6% cases. The mean value of RLLD/serum albumin ratio was 5.05 ± 1.90 in patients with varices versus 4.24 ± 1.64 in patients without varices (P = 0.023). The mean value of the LLLD/serum albumin ratio was 2.41 ± 0.90 in patients with varices versus 1.89 ± 0.61 in patients without varices (P < 0.001). Areas under curve were 0.377 and 0.69 for the RLLD/ serum albumin ratio and LLLD/serum albumin ratio, respectively. At a cut-off value of 1.5, the sensitivity was 88.1% and the specificity was 72.1% for the LLLD/albumin ratio. Conclusion: The LLLD/albumin ratio is a better predictor of esophageal varices than the RLLD/albumin ratio in patients with liver cirrhosis.

Background and Objective: Atrial fibrillation (AF) is the most common sustained arrhythmia. It is marked by disorganized, rapid and irregular atrial contraction. The aim of our study is to determine various clinical presentations in patients with AF and to assess the underlying heart disease in patients with AF using electrocardiography (ECG) and echocardiography. Subjects and Methods: This study was undertaken at the Vijayanagara Institute of Medical Sciences, Bellary. It was a prospective, observational study conducted from December 2010 to June 2012. Detailed history was taken from the patients and they were examined according to the prepared proforma. Results: The age of the patients varied from 30 to 85 years. In the present study, the male to female ratio was almost equal, with 24 (48%) male and 26 (52%) female cases. Dyspnea was the most common symptom, followed by palpitations. The pulse deficit varied from 10 to 26 per minute. Rheumatic valvular heart disease was the most common etiology of AF observed in the present study. Mitral stenosis was the most common valvular lesion observed in patients with rheumatic heart disease. Congestive cardiac failure was the most common complication observed, followed by embolic phenomenon. Left ventricular enlargement was seen in 18 cases on chest X-ray. Left atrial enlargement was seen in 33 cases, where 24 cases were of chronic valvular rheumatic heart disease on 2D echocardiography. Conclusion: AF was the most commonly seen rheumatic heart disease, followed by ischemic heart disease. Dyspnea was the most common presenting complaint and congestive cardiac failure was the most common complication.

Nonalcoholic steatohepatitis (NASH) is defined as the presence of hepatic steatosis and inflammation with hepatocyte injury (ballooning) with or without fibrosis. NASH is often a “silent” liver disease. Estimated prevalence of NASH ranges from 3% to 5% in different studies. The prevalence of NASH-related cirrhosis in the general population is not known. Herein, we report a case of a young female presented with NASH-related cirrhosis in the setting of poorly controlled celiac disease (CD) and microscopic colitis. A variety of liver abnormalities have been observed in patients with CD, but this unique constellation of the gut and liver pathologies has not been reported previously.

Choridal melanoma (CM) is a common ocular malignancy. We present here a case of a 62-year-old female with a CM with incidental diagnosis of pulmonary metastasis. The diagnosis of CM with incidental metastasis to lungs is rare and presents a therapeutic challenge to the physician in an otherwise healthy individual. The role of herbal medicine should be investigated further for the treatment of metastasis in CM.